Healthcare Provider Details

I. General information

NPI: 1306952890
Provider Name (Legal Business Name): KRISTAN M OUTWATER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 BELMONT AVE
BRATTLEBORO VT
05301-7110
US

IV. Provider business mailing address

600 BLAIR PARK RD STE 285
WILLISTON VT
05495-7586
US

V. Phone/Fax

Practice location:
  • Phone: 802-258-3905
  • Fax: 802-258-4903
Mailing address:
  • Phone: 802-288-1140
  • Fax: 802-288-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042-0012623
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number4301064412
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: